Provider Demographics
NPI:1447782339
Name:THOTTUKADAVIL, TONY (CO)
Entity Type:Individual
Prefix:MR
First Name:TONY
Middle Name:
Last Name:THOTTUKADAVIL
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8236 NW 160TH TER
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3350
Mailing Address - Country:US
Mailing Address - Phone:718-285-5398
Mailing Address - Fax:
Practice Address - Street 1:4207 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134
Practice Address - Country:US
Practice Address - Phone:405-525-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1744P3200X
OKC52463222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management